Prevention of recurrent urinary tract infections.

Urinary tract infections (UTI) are among the most frequent bacterial infections in the community and health care setting. Mostly young and, to some extent, postmenopausal women are affected by recurrent UTI (rUTI) defined as ≥3 UTI/year or ≥2 UTI/half year. In contrast, rUTI is rare in healthy men. On the other hand, rUTI are frequently found in female and male patients with complicating urological factors, e.g. urinary catheters, infection stones. Remediable predisposing factors in uncomplicated rUTI in women are rare. In complicated rUTI the success depends mainly on the possibility to eliminate or at leastimprove the complicating risk factors. Continuous antibiotic prophylaxis or postcoital prophylaxis, if there is close correlation with sexual intercourse, are most effective to prevent rUTI. Nitrofurantoin, trimethoprim (or cotrimoxazole), and fosfomycin trometamol are available as first-line drugs. Oral cephalosporins and quinolones should be restricted to specific indications. Antibiotic prophylaxis reduces the number of uropathogens in the gut and/or vaginal flora and reduces bacterial "fitness". Given the correct indication, the recurrence rate of rUTI can be reduced by about 90%. Due to possible adverse events and the concern of selecting resistant pathogens, according to the guidelines of the European Association of Urology antimicrobial prophylaxis should be considered only after counselling, behavioural modification and non-antimicrobial measures have been attempted. In postmenopausal patients vaginal substitution of oestriol should be started first. Oral or parenteral immunoprophylaxis is another option in patients with rUTI. Other possibilities with varying scientific evidence are prophylaxis with cranberry products, specific plant combinations or probiotics. The prophylaxis of catheter-associated UTI should employ strategies which result in a reduction of frequency and duration of catheter drainage of the urinary tract. The currently available catheter materials have only little influence on reducing catheter-associated rUTI.

[Recurrent and catheter-associated urinary tract infections : Prophylaxis and prevention]. / Rezidivierende und katheterassoziierte Harnwegsinfektionen : Prophylaxe und Prävention.

Urinay tract infection (UTI) as one of the most frequent bacterial infections in humans is of utmost relevance. Because of the rising prevalence of antimicrobial resistance, urinalysis should always include urine culture and a resistogram in order to avoid an unspecific selection and overuse of antibiotics. Prevention of recurrent UTI must first of all rule out predisposing uropathogenic conditions. Nowadays, a great variety of drugs, behavioral, and supportive treatment options can effectively minimize UTI recurrence. The growing importance of vaccines (immunotherapy), probiotics (lactobacilli), and standardized herbal preparations meets the need of reducing antibiotic use and the development of antimicrobial resistance. Around 80% of all nosocomial UTIs (nUTIs) are associated with indwelling urinary catheters. It is estimated that up to 70% of all nUTIs occurring in Germany may be avoided by using appropriate preventative measures. Therefore, profound knowledge about the basics of catheter-associated nUTIs and the correct management of urinary catheters are of utmost individual and socioeconomic importance.

[Symptomatic urinary tract infection of the female--diagnostics]. / Rezidivierende Harnweginfektion der Frau--Diagnostik.

The basis for the diagnostic work-up of recurrent cystitis is formed by taking a precise medical history against the background of knowledge of the pathogenesis of urinary tract infections. The anamnesis should also focus on factors that influence the natural flora (sexual intercourse, hygiene) but additionally include preceding antibiotic treatment and diseases that affect the immune status (diabetes mellitus). Urinalysis is the principal examination among the laboratory diagnostic procedures. The diagnosis is promptly confirmed by immediate analysis of a clean catch midstream urine sample using a counting chamber or a test strip. As a matter of principle, microbiological diagnosis always ensues. Extended diagnostic work-up (urological staging) is aimed at detecting functional and anatomic abnormalities. While these factors only play a subordinate role during the premenopausal phase, they gain in importance during the postmenopausal phase. A key role is also attributed to local estrogen deficiency.

[Prevention of Catheter-Associated Urinary Tract Infections]. / Infektionsprävention bei der Katheterdrainage der Harnblase.

With a share of 22.4%, nosocomial urinary tract infections (nUTIs) are among the most frequent infections acquired in hospitals, along with surgical site infections (24.7%), pneumonia (21.5%), clostridium difficile infections (6.6%) and primary sepsis (6%) 1. 80% of all nUTIs are associated with indwelling urinary catheters, with 12-16% of all hospitalised patients and up to 81.8% of all intensive care patients receiving an indwelling urinary catheter during their hospital stay 2 3. Therefore, profound knowledge about the basics of catheter-associated nUTIs and the correct management of urinary catheters are of utmost individual and socio-economic importance 4 5. It is estimated that up to 70% of all nUTIs occurring in Germany may be avoided by using appropriate preventative measures 6 7.In 2012, the authors Conway and Larson compared 8 recommendations in English language for the prevention of UTIs and noticed that they have been largely consistent over a period of 30 years 8. Special issues have rarely been addressed in valid studies, and study results are rather heterogeneous. For example, the 2008 SHEA (Society of Hospital Epidemiologists of America) guideline contains only 3 recommendations and 4 prohibitions which are based on more than one randomised controlled clinical study 9 10 11.The confirmed recommendations on the prevention of UTIs are consistent in the following aspects 12 13 14 15 16 17: · Every insertion of a urinary catheter must be based on a well-founded medical indication.. · Well-founded medical indications include acute urinary retention, interventions lasting several hours with a high fluid turnover, surgery involving the urinary tract, the necessity to record fluid turnover especially in critically ill patients, comfort for the dying, facilitating wound healing in the external genitals in the presence of urinary incontinence. Examples of unnecessary use of urinary catheters include prescriptions based on urinary incontinence alone and prolongation of use, e. g. after surgical procedures or after intensive care monitoring/recording has been completed.. · The insertion technique as well as catheter care and the detection of catheter-associated complications must be trained continuously.. · Catheterisation must be performed under sterile precautions.. · Only sterile and closed urinary drainage systems may be used.. · Catheters must be removed as early as possible..

[Therapy of hormone refractory prostate cancer: new standards, new trends]. / Die Behandlung des hormonrefraktären Prostatakarzinoms -- neue Standards, neue Trends.

Hormone-refractory prostate cancer is diagnosed with increasing incidence and has become a growing challenge for urologists. The improved understanding of the tumor biological mechanisms of the hormone-refractory state has led to innovative therapeutic developments in the field of hormonal and cytotoxic therapies. Recently, two large randomized Phase III trials with docetaxel-based chemotherapy were able to show prolonged survival and a positive influence on pain and quality of life, establishing a new standard of care for these patients. Moreover, bisphosphonates seem to have positive influence on selected patients. In the growing field of molecular targeted therapy, first trials with compounds, such as tyrosine kinase inhibitors, anti-sense oligonucleotides, angiogenesis inhibitors and endothelin receptor antagonists, show promising results in the treatment of patients with hormone-refractory prostate cancer.

[Obstructive uropathy in adults]. / Obstruktive Uropathie bei Erwachsenen.

Urinary tract obstruction is a common clinical problem. The obstruction of the urinary flow may be acute or chronic, partial or complete, unilateral or bilateral, and may occur at any site of the urinary tract. The major causes of urinary tract obstruction vary with the age of the patient. Anatomic abnormalities, e. g. ureteropelvic junction obstruction, account for the majority of cases in children. In comparison, calculi are most common in young adults, while prostatic hyperplasia or carcinoma, retroperitoneal or pelvic neoplasms, and calculi are the primary causes in older patients. Urinary tract obstruction results in different pathophysiological changes causing various symptoms. In addition to the aetiology, pathophysiology and clinical presentation of obstructive uropathy in adults, modern diagnostic and therapeutic options are presented in this review.

Free ureteral replacement in rats: regeneration of ureteral wall components in the acellular matrix graft.

OBJECTIVES: To evaluate ureteral replacement by a free homologous graft of acellular matrix in a rat model. METHODS: In 30 male Sprague-Dawley rats, a 0.3 to 0.8-cm midsegment of the left ureter was resected and replaced with an acellular matrix graft of equal length placed on a polyethylene stent. The animals were killed at varying intervals, and the grafted specimens were prepared for light and electron microscopy. RESULTS: In all animals, the acellular matrix graft remained in its original position without evidence of incrustation or infection, and histologic examination showed complete epithelialization and progressive infiltration by vessels. At 10 weeks, smooth muscle fibers were observed; at 12 weeks, nerve fibers were first detected; at 4 months, smooth muscle cells had assumed regular configuration. CONCLUSIONS: The ureteral acellular matrix graft appears to promote the regeneration of all ureteral wall components.

[Catheter drainage of the urinary tract. Status of the technique and prospects]. / Katheterdrainage des Harntrakts. Stand der Technik und Perspektiven.

In the last few years, progress in the field of catheter drainage of the urinary tract was limited to the introduction of some new devices, materials, and catheter coatings as well as specific points of technique [37]. At the same time a substantial number of evidence-based guidelines for the use of urinary catheters have been developed by various institutions [9, 13, 15, 17, 23, 28, 39], aiming at a reduction of catheter-associated nosocomial urinary tract infections. Based on these guidelines, this article provides a detailed overview of the current state of the art of catheter drainage of the urinary tract, focussing on practical aspects and hygiene. Urinary tract infections (UTI) still account for 30-40% of all nosocomial infections nowadays, while 90% of these nosocomial UTIs are associated with urinary catheters! The prevention of catheter-associated nosocomial UTIs, therefore, is an individual as well as infectiological and socioeconomic issue of utmost importance requiring cost-effective surveillance strategies and modern individualized concepts for the catheter drainage of the urinary tract in a multidisciplinary approach. Continuous training and education must ensure the above-mentioned medical standards since nurses, outpatient health care networks, and patients themselves increasingly assume the management of catheter drainage of the urinary tract. Because of their unique and specific expertise, urologists have to take responsibility and must play a key role in these projects.

[Diagnosis of interstitial cystitis]. / Diagnostik der interstitiellen Zystitis.

Interstitial cystitis (IC) represents a rare and complex inflammatory bladder condition in which diagnostics can be challenging. Strict NIH criteria for its diagnosis were designed for research purposes. Their routine application would miss large proportions of IC patients. When IC is suspected, history and physical exam are followed by an evaluation of long-term voiding diaries. Large voided volumes (functional capacity > 250 cc) or longer micturition intervals (> 2 h.), absence of nocturia or symptom-free periods reduce the likelihood of IC. Further exclusion diagnostics include urine tests (infection), cytology (in-situ carcinoma), ultrasound (calculi, bulks, anomalies) and urodynamics in selected cases. Bladder capacity measurements under sedoanalgesia are of limited value, since functional low-volume bladders can be mechanically extendable. Cystoscopy under general anesthesia represents the diagnostic standard procedure for IC during which 90% of IC-patients present with characteristic mucosal glomerulations after bladder distension. Biopsies are recommended for exclusion of malignancy. Potassium-leak testing plays no relevant role in routine diagnostics due to its poor sensitivity. Similarly, complex determinations of novel IC markers (histamine, tryptase, cytokines, growth factors, substance P, nitric oxide) are of no relevance in clinical settings and should be restricted to research projects.

[Oral therapy of interstitial cystitis]. / Orale Therapie der interstitiellen Zystitis.

Up to now there is no specific treatment targeting the ultimate cause of interstitial cystitis (IC), since its pathogenesis and etiology are still unknown. Most studies focussing on oral medication have not been randomized, double-blinded or placebo-controlled. Numerous case reports and intent-to-treat trials are lacking a systematic approach and do not meet evidence-based medicine criteria. Consequently there is as yet no standard oral therapy available for the treatment of IC. However, only a few oral substances have shown a potential to improve symptoms such as frequency and pain. The best results were obtained from monotherapeutic use of pentosanpolysulfate, amitriptylin and hydroxycin. The true benefit of these substances alone should be compared to analgesics and anticholinergics in the course of controlled clinical trials.

[Benign fibroepithelioma of the ureter. A rare differential diagnosis for pain-free macrohematuria]. / Das benigne Fibroepitheliom des Harnleiters. Seltene Differenzialdiagnose der schmerzlosen Makrohämaturie.

Gross hematuria without pain is a classical symptom of malignancy in the urinary tract. Despite the presence of other symptoms such as a history of heavy smoking or radiologic evidence of tumor growth, it may still be caused by a benign lesion. This is demonstrated by the case of a 38 year old man with a fibroepithelioma of the left ureter. While discussing the differential diagnostic and treatment procedures it is shown that even in the era of modern non-invasive imaging techniques there is still an important place for retrograde ureteropyelography in the evaluation of the upper urinary tract.

[Rational diagnosis and surgical therapy of renal cell carcinoma with tumor thrombosis in the vena cava]. / Rationelle Diagnostik und operative Therapie des Nierenzellkarzinoms mit Tumorthrombus in der V. cava.

Venous involvement in renal cell carcinoma (RCC) represents an advanced state of disease. Nonetheless, its influence on survival is rather secondary compared with that of local tumor growth, grading and metastasis. Since conservative treatment in advanced RCC is mainly ineffective, surgical management offers the most promising approach for potential cure. Only patients without metastasis, however, seem to benefit from an aggressive surgical intervention. The surgical technique itself is determined by the vena caval extent of the tumor thrombus. Preferably, noninvasive imaging techniques should provide information about metastasis and the extent of the tumor thrombus. Diagnostic efforts should be adapted to therapeutic feasibility and prognosis in every individual patient in order to avoid fatiguing and costly over-examination. The standards requested above can be realized by use of modern sonographic and computed-tomographic imaging techniques or by magnetic resonance imaging alone. Thus, nowadays, the essential diagnostics in RCC with vena caval involvement may dispense with angiographic examinations.

[Diagnosis of urethral diverticulum in women]. / Diagnostik des weiblichen Harnröhrendivertikels.

Urethral diverticula have proved to be a common cause of recurrent urinary tract infections in female subjects. Positive-pressure urethrography, mostly performed by means of double-balloon catheters, has hitherto been regarded as the method of choice for their detection. Unfortunately, the few existing commercial catheter devices have certain disadvantages, which have led to a lack of acceptance of this important technique and restricted its use. We therefore present an improved tool for positive-pressure urethrography and a synopsis of diagnostic visualization procedures for urethral diverticula in women.

[Gemcitabine/cisplatin vs. MVAC. 5 year survival outcome of the phase III study of chemotherapy of advanced urothelial carcinoma in Germany]. / Gemcitabin/Cisplatin vs. MVAC. 5-Jahres-Ergebnisse der Phase-III-Studie zur Chemotherapie des fortgeschrittenen Urothelkarzinoms in Deutschland.

Of 405 patients with stage IV transitional cell carcinoma from an international multicenter phase III trial, 70 were randomized in Germany to receive either gemcitabine/cisplatin or standard MVAC systemic chemotherapy for locally advanced or metastatic urothelial cancer. Overall survival as the primary endpoint of the study was similar in both arms (median survival GC 15.4 months vs MVAC 16.1 months), as were tumor-specific survival and time to progressive disease. In the intent-to-treat analysis, the 5-year overall survival rate was 10% for patients randomized to GC and 18% randomized to MVAC. Tumor overall response rates (GC 54%, MVAC 53%) were similar. The toxic death rate was 0% in the GC arm and 3% (one patient) in the MVAC arm. Significantly more GC than MVAC patients experienced grade 3/4 anemia (GC 52%, MVAC 20%) with significantly more red blood cell transfusions in the GC arm.Significantly more GC than MVAC patients had grade 3/4 thrombocytopenia (GC 54%, MVAC 17%) without grade 3/4 hemorrhage or hematuria in either arm. More MVAC patients experienced grade 3/4 neutropenia (GC 56%, MVAC 61%, p=1.000), neutropenic or leukopenic fever (GC 0%, MVAC 10%, p=0.237), mucositis (GC 0%, MVAC 7%, p=0.495), and alopecia (GC 6%, MVAC 36%, p=0.004). GC represents a reasonable alternative for the palliative treatment of patients with locally advanced and metastatic transitional cell carcinoma. Sustained long-term survival was only found for patients with locally advanced cancer, lymphatic metastases, or solitary distant metastasis but not for visceral metastatic disease.

[European Association of Urology guidelines on urinary and male genital tract infections]. / Synoptische Leitlinie der sexuell übertragbaren Erkrankungen (STD) mit Primärsymptomen im männlichen Genitale (S1). Leitinien der Deutschen Gesellschaft für Urologie.

Today, the classical bacteria that cause venereal diseases, e.g. gonorrhea, syphilis, chancroid and inguinal granuloma, only account for a small proportion of all known sexually transmitted diseases (STDs). Other bacteria and viruses as well as yeasts, protozoa and epizoa must also be regarded as causative organisms of STD. Taken together, all sexually transmitted infections comprise more than 30 relevant STD pathogens. However, not all pathogens that can be sexually transmitted manifest diseases in the genitals and not all infections of the genitals are exclusively sexually transmitted. Concise information and tables summarising the diagnostic and therapeutic management of STDs in the field of urology allow a synoptic overview, and are in agreement with the recent international guidelines of other specialist areas. Special considerations (i.e. HIV infection, pregnancy, infants, allergy) and recommended regimens are presented.

[Nosocomial infections in urology]. / Nosokomiale Infektionen in der Urologie.

Nosocomial infections (NI) may be a serious and mostly avoidable consequence of medical procedures and often cause a significant aggravation of the patients underlying disease. Following surgical site infections, urinary tract infections (UTI) represent the second most common fraction of NIs (22.4%) in Germany and contribute to approximately 155,000 nosocomial UTIs (nUTI) every year.Prevention of NI is of utmost individual as well as socioeconomic importance especially regarding the continuing worldwide increase in antibiotic resistance. National legislature has responded to this challenge by amending the German Law on the Prevention and Control of Infectious Diseases (IfSG) and other measures. Their practical importance for various clinical settings in urology is outlined in this overview.The correct use of urinary catheters has the greatest impact for prevention and control as nUTIs are associated with urinary catheters in most of the cases (80%). The recently updated guidelines of the Commission for Hospital Hygiene and Infection Prevention of the Robert Koch Institute (KRINKO) and the Association of the Scientific Medical Societies in Germany (AWMF) provide detailed recommendations in an evidence-based and practice-oriented manner as summarized in this article.

[Prophylaxis of recurrent urinary tract infections]. / Prophylaxe rezidivierender Harnwegsinfektionen.

BACKGROUND: Recurrent urinary tract infections (rUTI), defined as ≥ 3 UTIs per year, mostly affect young and postmenopausal women. Treatable predisposing factors are rare. METHODS: General recommendations to reduce rUTIs lower the recurrence rate by up to approximately two thirds. Continuous long-term prophylaxis (LP) with low dose antibiotics or single postcoital doses can reduce the recurrence rate of rUTIs to as low as 5%. According to the European Association of Urology guidelines nitrofurantoin, trimethoprim and co-trimoxazole are the first-line drugs and cephalosporins or fluoroquinolones should be restricted to specific indications. Oral and parenteral immunotherapy were found to be effective in several controlled studies for prevention of rUTIs and can be combined with acute antibiotic therapy. CONCLUSIONS: Vaginal prophylaxis with estriol has proven its positive effect without serious gynecological side effects and there is also increasing evidence that cranberries prevent rUTIs but the exact mode of this therapy remains to be defined. There are also other promising modalities, such as phytotherapeutics, mannose, urine acidification, influencing bacterial intestinal and vaginal flora and the general immune response by e.g. acupuncture and inpatient rehabilitation, the therapeutic value of which still has to be proven.

[Secondary malignancies in urinary diversions]. / Sekundärmalignome in Harnableitungen.

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

[Primary and secondary prevention of urinary tract infections]. / Primär- und Sekundärprävention von Harnwegsinfektionen.

Urinary tract infections (UTI) are among the most frequent bacterial infections in the community and health care setting. Mostly young and, to some extent, postmenopausal women are affected by recurrent UTI (rUTI) defined as ≥3 UTI/year. On the other hand rUTI are frequently found in patients with complicating urological factors, e.g. urinary catheters. Modifiable predisposing factors in uncomplicated rUTI in women are rare. Continuous antibiotic prophylaxis or postcoital prophylaxis, if there is close correlation with sexual intercourse, are most effective to prevent rUTI. Nitrofurantoin, trimethoprim (or cotrimoxazole), and fosfomycin trometamol are available as first-line drugs. Oral cephalosporins and quinolones should be restricted to specific indications. Antibiotic prophylaxis reduces the number of uropathogens in the gut and/or vaginal flora and reduces bacterial"fitness". Given the correct indication, the recurrence rate of rUTI can be reduced by about 90%. In postmenopausal patients vaginal substitution of oestriol should be started first. Oral or parenteral immunoprophylaxis is another option in patients with rUTI. Other possibilities with varying scientific evidence are prophylaxis with cranberries or probiotics. The prophylaxis of catheter-associated UTI or asymptomatic bacteriuria should employ strategies which result in a reduction of frequency and duration of catheter drainage of the urinary tract. The currently available catheter materials have only little influence on reducing catheter-associated rUTI.